**4. Potential causes of depression, anxiety, and stress in medical students**

This section will explore the sources of psychological distress among medical students. Various potential sources of mental distress found in literature among medical students are discussed below.

### **4.1 Academic demands**

## *4.1.1 Vast syllabus*

The medical curriculum had long been identified as one of the important risk factors for distress among students. Several studies recognized assessments and academic-associated elements as the most substantial stressors [7, 22, 25, 32]. A longitudinal study in the UK concluded that the enormous academic load is the most significant reason of mental distress among medical students [35]. Studies have shown that the mental health of many students deteriorates after their enrollment in medical school and remains low throughout their training [9, 17, 22]. The poor mental health of medical undergraduate affects not only their physical well-being but also their educational achievements during their training period [9]. Some degree of stress facilitates learning and performance, but intense pressure and huge demands of the medical curriculum may have undesirable effects on vulnerable students' behavior which reduces their learning abilities [36]. There is evidence that prolonged stress exposure may affect the prefrontal area of the brain, which is responsible for higher cognitive functions and learning [37]. Stress and anxiety not only cause underachievement but also result in low-level self-esteem and reduced motivation and effort to complete educational tasks [6]. Poor and unsatisfactory academic achievement may further increase the mental distress among students [15] which may have serious consequences, e.g., dropout from medical course or suicide in extreme cases [38].

#### *4.1.2 Frequent exams*

Frequent examinations are found to be another main reason for mental stress. A study revealed that the amount of stress almost doubled during or near the examination [25]. Moreover, due to frequent examination and assessments throughout the academic year, it becomes difficult for students to prepare for the exams properly; as a result, they get an average or poor grade [39]. Adults are motivated to learn mostly by internal factors, but external sources such as assessments also contribute strongly to motivate the learner to learn [40]. Too many examinations do not let students study deep, and they failed to produce intended outcome or good grades, hence becoming demotivated and distressed [41].

#### *4.1.3 Inadequate feedback*

Dahlin et al. [10] mention that insufficient feedback is also related to increased distress of students. It is very crucial to give effective feedback to students because it enables the learner to analyze their actions and helps them plan for the future; learners can be confused if left unsupervised [42]. Effective feedback practice from teachers permits students to develop positive insights about the task, and corrective feedback is essential for effective learning; without it the level of performance attained is lower [40].

#### *4.1.4 Lack of time*

In a semi-structured interview-based study, students revealed that huge academic tasks render them to have limited or no time for sleep and recreational activities; this lack of sleep might reduce the emotional well-being of students [43]. Due to high academic demands of medical education, most of the medical students fail to take time out for physical activities like exercise and other healthy activities [39]. People who have minimal physical activity are at higher risk of mood disorders like depression, anxiety, and stress [44]. Medical students get fewer opportunities for extracurricular activity, and that might have a negative effect on their mental health. Due to lack of time and the heavy burden of study, students could not find enough time for self-care; they are not able to take proper sleep and time for leisure activities which have a further bad effect on their well-being [45].

#### **4.2 Transition**

The literature offers evidence of the association between transitions and students' mental distress [5, 7, 10, 16, 31]. Transition is a dynamic process in which students experience cultural, social, and cognitive challenges while passing from a familiar to a less familiar environment. The medical curriculum is interrupted by two major transitions, first from the high school to the first year of medicine and another from preclinical to clinical, i.e., third year. Dahlin et al. [10] explored the distress among different years of students and found higher mental distress among first-year and third-year students than senior level year students.

#### *4.2.1 Transition from high school to the first year of medicine*

Students of the first year are overburdened with huge subjective curriculum, the pace of study is too fast, and they have little time to cover the syllabus. However, Dyrbye et al. [20] argued that many junior students might face the challenges of

#### *Mental Distress among Medical Students DOI: http://dx.doi.org/10.5772/intechopen.91864*

being displaced from friends and family and experience difficulty in adjusting to a new environment along with heavy academic toll. So this high mental distress might be a part of the adjustment process to the new educational setting. According to the U-curve theory, this stage of adjustment is known as "culture shock" in which a medical student faces isolation, stress, anxiety, and emptiness [46, 47]. The successful adjustment at this stage depends on the self-confidence of students in their ability to cope with the stressors [48, 49]. In this stage, a student must face numerous challenges to adapt in a new environment as well as meet academic demands [48, 49]. So, in this context, self-efficacy seems to be the most suitable principle to deal with stress [50]. Bandura [21] concludes that cooperative learning strategies, in which learners work together and help one another, tend to improve both selfefficacy and academic achievement. Furthermore, constructive feedback is also important in developing self-efficacy in students [21].

### *4.2.2 Transition to clinical phase*

A study done in a Thai school revealed a higher mental stress among third-year medical students [5]. Students are susceptible to become depressed during their initial clinical years of study when they rotate through the hospitals, because at that time students often detach from their friends and peer group and must work with constantly changing groups of residents and attending physicians at different hospitals [43]. Furthermore, clinical rotations anticipate a number of stress-provoking tasks, such as interactions with senior doctors and staff during ward rounds; dealing with patients, diseases, and death may also contribute to the poor mental health of medical students during their initial clinical years [15], because at this stage, students are not able to contribute enough to the patient care which makes them feel insecure about not having enough knowledge and skills [43]. Students, when entering into the clinical stage, are not confident enough to communicate effectively with clinical staff and are hesitant to participate in teamwork. It is evident that stress has been associated with poor communication, reduced quality of patient care, and medical errors [51].

### *4.2.3 Lack of communication skills*

Students find it difficult to deal with newly added tasks and interacting with critically ill patients. Undergraduate curriculum mostly does not contain any information about communication skills. Effective communication builds a strong relationship between students, clinical staff, and patient which ultimately reduces the distress of students and enhances learning [52], and this will ultimately affect the quality of care delivered to the patient and quality of life [53]. These transitions might have negative effects on the learning process due to the lack of social interaction. Students who are distressed may face isolation and stigma which further affect their learning. Social constructivism theory describes that the adult learner learns through interaction and collaboration with other people in their natural setting [54]. Students learn better when they interact with their friends and peers regularly [55].

These large changes during the period of transitions need coping strategies in order to function effectively in the new environment. Critical reflection is the most desirable quality for a smooth transition [56, 57]. Experience is converted into learning by reflection, and this process can be improved by the cooperation of a facilitator or teacher [58]. Encouraging reflection in learners will lead to the development of reflective practice which is a significant element of

professionalism [59]. Learners should be involved in assessing their own learning process. Critical reflection on experience promotes deep and self-directed learning among students [40]. Mann [53] argues that introduction of activities like reflective portfolios, feedback, and peer review helps students cope with the stress during the transition and avail opportunity of learning during the transition phase. It is also noted that early introduction of clinical medicine also aids to stimulate smooth transitions [60].

#### **4.3 Miscellaneous causes of mental distress**

In addition to the aforementioned reasons, some other causes are also mentioned in the literature, e.g., personal life events, the death of family members, marriage, the birth of a child, family history of depression, etc. These reasons are also recognized to contribute to depression, anxiety, and stress in medical students, the same as the general population [61]. Financial problems are another factor mentioned in various studies, as a cause of increased stress levels in medical students [25]. A study discovered that the poorer the background, the more stress is experienced by students [25]. Medical education is considered a costly course which is also associated with other demands such as expensive textbooks, suitable clothing, and medical equipment. Some medical students suffer financial problems. Long academic hours do not allow students for part-time jobs to fulfill their financial needs [15]. Finances would be one of the main factors of the distress among students. As a medical educationist, we cannot do much about this issue, but we can suggest stakeholders create more scholarship opportunities for students.

#### **4.4 Educational interventions that contribute to student well-being**

Literature is largely focused on the efforts to improve student mental health through improving access to mental health provider and decreasing the stigma to mental health treatment and implementing of wellness programs. But there are only a few studies focused on innovative models that build to address the root causes of stress, i.e., academic related. The few most frequent curricular-related recommendations to improve the well-being of students are as follows.

#### *4.4.1 Grading system*

Implementation of the pass/fail grading is the most common curricular innovation mentioned in the literature. Reed et al. [60] found in a multi-institutional study that levels of mental distress are higher in students of the medical institute that used grading system with three or more levels than the students of the medical institute that used pass/fail grading [62]. Students always do a competition for getting better grades, and that consistently caused distress. Implementation of the pass/fail grading system, especially during the initial 2 years of medical school, helps students not to over-occupy themselves with competition for the high grade [15].

#### *4.4.2 Clear learning objectives*

Evans and Brown [61] proposed that students can be helped to reduce academic burden by offering them a clear learning objective so that students will know what they have to learn. It reduces the distress and thus fosters the well-being of students [63]. A predetermined clear learning objective not only lets students focus on them but also motivates them to achieve those [64].

### *4.4.3 Teaching strategies*

Offering a variety of teaching strategies for delivering of course material such as small group activities, team-based learning, and flipped class is also known to reduce mental distress [65]. Small group learning is a more effective tool in gaining student-teacher bonding than didactic traditional lectures and thus helps the transfer of knowledge efficiently [66]. Furthermore, a small group setup provides a secure state in which students can argue and discuss their perceptions and assumptions. This problem solving and peer interaction can result in deep understanding; group discussion complements the situational learning of professionalism [66] which is known to enhance the well-being of students [57].
